Dog Questionnaire

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If you have any questions regarding the process, please call us on 01244 377365 or email office@brvp.co.uk

Please ensure that all required fields are completed before submitting the form. Once the form has been submitted, you will receive email confirmation and a member of the team will contact you with regards to the next steps. If you do not hear from a member of the team within a week of submitting the form, please contact the office.

Questionnaire

Please take time to carefully read questions below and answer them as comprehensively as possible. The more accurate the information is, the better our clinical staff can start to understand your concerns and enable us to offer you the most appropriate appointment.

Please ensure that all of the fields are filled in order for your form to be submitted.

Please note: The information we receive will be used solely for the diagnosis and treatment of your pet.

Dog referral form

Please complete this form only if you have been explicitly requested to do so and have received it via a link directly from BRVP.

"*" indicates required fields

Contact Details

Name*

Prefix First Last

Occupation

Address*

Street Address Address Line 2 City County Postcode

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Primary Contact

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Name of holder

Primary Email*

The provided email address will be used as the primary contact, as we are unable to store or correspond with multiple email addresses.

Phone number*

Alternative phone number:

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2) What is your preferred method of communication when sending you documents?

Royal mail

Pet Details

Name of pet(s) referred to Behavioural Referrals*

Is your pet insured?*

Yes

With which company?*

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What is the name of your policy type?

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What is the policy number(s)

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What is the excess?

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Policy start date

DD slash MM slash YYYY

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Renewal Date

DD slash MM slash YYYY

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Does your policy cover behaviour?

Yes

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Does your policy recognise Veterinary Behavioural Medicine and include claims under veterinary fees?

Yes

In your own words please give a brief description of the concerns you have about your pet’s behaviour*

Do any of the following describe your pet’s reaction to unfamiliar people?*

Greets calmly

Greets with great enthusiasm

Greets reluctantly

Avoids completely

Scratches or bites

Is there any history of aggression?*

Yes

When was this first noticed?*

DD slash MM slash YYYY

Has your pet bitten anyone?*

Yes

Who was bitten (e.g. child/adult, familiar/ unfamiliar person)*

Where was the bite? (e.g. fingers, hand arm ankles, face)*

Has your pet bitten/attacked another animal?*

Yes

What animal was bitten/attacked? (e.g. dog/ cat/ other species, adult/ puppy/ kitten, familiar/ unfamiliar animal)*

Medications or supplements in use if any, or that have been tried in the past?

Please provide information on the animals referred.*

Name

Species

Breed

Colour

Sex

Date Neutered

Weight (kg)

Date of Birth

Date of Acquisition

Remarks

Please provide information on any other animals in your household (those that are not referred).

Name

Species

Breed

Colour

Sex

Date Neutered

Weight (kg)

Date of Birth

Date of Acquisition

Remarks

Please provide details of ALL people that live in the house OR people who are present in the house on a regular basis (including yourself). By including people in this table, you are confirming that you have their consent for us to process and store their details.*

Relationship

Name

Age

Sex

Approx. time around house

Remarks

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A Virtual tour of the house.

Max. file size: 128 MB.

Please submit a brief home tour video showing the rooms your pet uses, in particular where they eat, drink and rest along with entry/exit points if relevant. Please briefly commentate on the resources relevant to your pet in each room. These videos help us plan our consultation and tailor our approach to each family and in many cases mean we are better able to manage a patient’s behaviour during the consult by moving around their home less than we would need to without this information.

Please provide information on advice sought from any other sources such as behaviourists, breeder etc if any (please indicate which pet(s) was/were involved)?

Pet’s Name

Date started

Date stopped or ongoing

Source of advice

Reason for their involvement

Please include behaviourist name/company if known.

Is your pet currently or has your pet previously received care from another veterinary practice?*

Yes

Please specify veterinary practices/referral centres/specialists:

Additional Information

Sharing of information

There may be instances where we may need to consult with your referring Veterinary Practice. This may be due to medical problems noticed during consultations, requirement for blood tests because of medication, allergy testing and other reasons. A summary will be sent to your veterinary practice after consultations, and we may request a full clinical history from veterinary practices where your pet(s) has been registered.*

I agree to medical information being shared.

A Veterinary student/resident may be present during your appointments, for observation purposes only. Would you be ok for a student to attend?*

Yes

Consent*

I hereby confirm that all of the information given in this document is accurate to the best of my knowledge. Based on the information provided by Behavioural Referrals Ltd I wish to proceed with the referral process under the terms as set out above.

Out of hours service*

I understand that if my pet should require emergency care out of hours , I will contact my general veterinary practice.

Consent

Consent*

I confirm that I have read and understood this, including Behavioural Referrals Ltd’s Terms and Conditions of Business and Privacy Policy, and agree to comply with the requests and requirements contained within.

During your relationship with Behavioural Referrals Veterinary Practice, it is important that we have your consent to keep your personal data on record. If we do not have this then we cannot proceed with treatment.

Please be aware that we are a teaching veterinary practice and this means that there might be a student at your appointment. Students observe sessions but do not offer advice or opinions. Our top priority is the welfare of your pet, so if we feel that it is not suitable for a student to be there then we will not bring them or ask them to leave if necessary.

During appointments, we take videos and pictures. This allows us to discuss your case internally at our clinical meetings and also, where applicable, with other professionals, to make sure that your animal has the best care possible. In any other instance, we will get your consent.

By signing this form, you acknowledge that services and products will incur additional costs, which will be itemised in your invoice. These may include, but are not limited to, appointments, medications, products and administration fees. You agree to cover these additional charges as part of the comprehensive care provided. An estimate of costs can be provided upon request.

Consent for Videos, Pictures and clinical information

I agree to have videos or photographs and anonymised clinical information used for educational and research purposes

We would like your permission to use video footage, photographs of you and your pet for further education and research purposes and to be included in promotional material including use on our Facebook page. This includes videos and pictures that were taken at appointments or that you have sent in. All videos and pictures are used anonymously. If there is a video or picture that you wish for us not to share then please let us know. You have the right to withdraw consent at any time.

We also seek permission to use anonymised clinical information (such descriptions of your pet’s breed, age and neuter status, their presenting signs, our clinical intervention and their response to this) for further education and research purposes.

Educational and research purposes includes the use of videos and pictures at lectures and conferences and in research projects, teaching, books, articles and on social media as an educational tool.

Promotional includes the use of videos and pictures on adverts, leaflets and social media to promote our business.

If you are happy to give us this permission, please tick the box above.

I hereby grant Behavioural Referrals Ltd the right and permission to use photographs, videos and/or anonymised clinical information relating to me & my pet in publications, educational and research materials, derivative works, or for any other similar purpose without compensation to me. In all cases, my anonymity will be protected.

I understand and agree that such photographs and/or video recordings of me may be placed on the Internet. I also understand and agree that I will not be identified by name and/or title in printed, Internet or broadcast information that might accompany the photographs and/or video recordings of me. I waive the right to approve the final product. I agree that all such portraits, pictures, photographs, video and audio recordings, and any reproductions thereof, and all plates, negatives, recording tape and digital files are and shall remain the property of the Behavioural Referrals Ltd.

I hereby release, acquit and forever discharge Behavioural Referrals Ltd, its current and former trustees, agents, officers and employees of the above-named entities from any and all claims, demands, rights, promises, damages and liabilities arising out of or in connection with the use or distribution of said photographs, video recordings and/or anonymised clinical information, including but not limited to any claims for invasion of privacy, appropriation of likeness or defamation.

I hereby warrant that I am eighteen (18) years old or more and competent to contract in my own name or, if I am less than eighteen years old, that my parent or guardian has signed this release form below. This release is binding on me and my heirs, assigns and personal representatives.

Date*

DD slash MM slash YYYY